A Week in the Life of a Community Hospital Pathologist
Murray Treloar, MD, FRCPC
Murray Treloar, MD, FRCPC, is the chief of medical staff and the chair of the Medical Advisory Committee at Lakeridge Health, as well as chief and medical director of Laboratory and Genetic Services. He also holds appointment as a lecturer in the Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario. E-mail: mtreloar@lakeridgehealth.on.ca.
Let me begin by saying that I feel honoured to participate in the inaugural issue of Canadian Journal of Pathology. What follows is a fictional, informal (and entertaining, I hope) report on a typical week in the life of a community hospital pathologist.
Monday
Monday followed a week away attending a College of American Pathologists meeting. I find such meetings essential as I approach 30 years in practice, not only for the content but also for the renewed friendships. The update on PUMP (Pathologist of Uncertain Malignant Potential)1 was particularly interesting and should help me in my role as laboratory director.
On call for frozen sections, the cases were the usual skin margins and a not-so-usual bronchial resection margin. In the afternoon, I met with our medical microbiology infectious disease consultant in our monthly review of the micro laboratory operations with the charge technologist. It was interesting to hear about the usefulness of our decision to introduce Clostridium difficile toxin (CDT) testing. In-house CDT testing had allowed patients to leave the hospital earlier and had reduced costs for nursing. That should be enough ammunition to explain our budget variance to the vice-president later on. My workday ended at around 6:00 p.m., after reading out some peripheral blood morphology at a local community laboratory where I am a consultant.
Tuesday
Tuesday started with the 7:30 a.m. meeting of the Steering Committee on the planned expansion of cancer and surgical programs. I pointed out that our pathologists are fully occupied keeping up with the flood of gastrointestinal and breast biopsies since the screening programs were implemented earlier this year. The proposed addition of five oncologists would require two more pathologists, bringing our number to 10. I supported this statement with workload information and the benchmark study published in American Journal of Clinical Pathology by Dr. Raymond Maung,2 a CAP member and friend. I mused that Dr. Maung may have published his Canadian study in our own journal, if it had existed at the time.
Later Tuesday, I did an autopsy on a 46-year-old man who had died of a pulmonary embolism after an elective orthopedic procedure. The surgery was at another hospital in our region, but the autopsy was here because we are the only group still doing autopsies. Among the eight pathologists in our group, we manage to handle about 400 autopsies, mostly coroner’s cases. There was no mystery as to the cause of death, but perhaps I could help prevent another patient dying by looking into current best practice for thromboprophylaxis in elective arthroscopy. A call to our hematologist deflated my balloon – there is no recommendation for routine thromboprophylaxis in arthroscopy unless there is a history of deep venous thrombosis. I told the coroner to advise the family members about testing for a clotting tendency.
I spent the afternoon signing out cases and attended a meeting with the vice-president of medical affairs. I sent regrets to the Hospital Quality Committee because I had cases piling up on my desk.
Wednesday
Wednesday noon, I met with my pathologist colleagues in our monthly meeting. We had the usual gripe session about slow histology and clerical turnaround times. Then my colleague, Dr. Smith, reviewed the quarterly cases we had sent to the local reference centre against our internal diagnosis. She pointed out that we seem to be doing a good job, except for recognizing a follicular variant of papillary thyroid carcinoma. She recommended that we invite our reference thyroid pathologist to present rounds the following month.
Thursday
Thursday morning, I was in one of our peripheral sites. Our hospital has operating rooms on three sites, and we provide routine pathology services only at the main site. We travel to the other sites for frozen sections, as needed. While I was waiting for the skin specimen to arrive, I reflected on the telepathology displays at the CAP meeting a week earlier. Dr. Andy Evans, from University Health Network (UHN), had presented his group’s three-year experience with telepathology supporting frozen section diagnosis at one of their satellite sites. No more travel and waiting game for the UHN pathologists. Our hospital is so cash starved that I can only dream of a similar arrangement here.
Back at my home hospital, I participated in the Privileged Staff Appointments and Credentials Meeting over lunch. Later, I welcomed our new pathology assistant, an international medical graduate and pathologist in China before immigrating. Our previous pathology assistant left for a PGY 2 position in a pathology residency program. I was grateful that Canada continues to attract such well-qualified people, awed by their willingness to repeat training in Canada, and dismayed that, as a country, we are unable to provide for our own medical human resource needs.
Friday
Friday was my “clean-up” day, when I completed transcribed reports. Our dictations are usually 2–3 days backlogged since the hospital cutbacks. I looked forward to the installation of voice recognition planned for next month. While learning a new work method would be challenging, it would allow our reports to reach the clinician much sooner.
Over the noon hour, I presented a teleconference to the provincial pathologist network. My topic was reporting our experience in synoptic reporting using our computer system – the most common system in Ontario. Most of my talk was about add-on software and workarounds for the basic system, a 20-year-old LIS that does not allow us to meet current Cancer Care Ontario standards without such add-ons. I figure that 20 years in computer terms must be about 100 years in human terms. I wonder how much longer until it reaches DNR status.
A Career That Is a Blessing
So, that finished off a busy week. It is typical of my role in the past few decades in the community, mixing AP with clinical laboratory responsibilities, some leadership, a bit of informatics, and participation in hospital and regional committees. It also provides some opportunity for limited innovation in how we do our jobs. The use of computers in pathology is an example. The frustrations are often about funding shortfalls and sometimes about personality conflicts.
I enjoy coming to work as much today as I did 30 years ago, and that is a blessing. I encourage residents to consider a community hospital career. As you likely know, I think general pathology is the best preparation and within the reach of any medical student who loves science.
References
1. Bachner P, Hernandez JS, Katz DA. PUMP—the pathologist of uncertain malignant potential or how to understand and manage difficult colleagues. Presented at the meeting of the College of American Pathologists; 2008 Sept 25–28.
2. Maung RT. What is the best indicator to determine anatomic pathology workload? Canadian experience. Am J Clin Pathol 2005;123(1):45–55.
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